Transcript

Norman Swan: Hello from me, Norman Swan, and welcome to the program. Today's Health Report is about your back, including helping to unhook your doctor from doing scans of your spine when it's sore, because an MRI or a CT of your back could do more harm than good.

Richard Deyo: In this study MRI scans were done on a large group of patients, but only half were given their results, and it turned out that the patients who did not get the results actually reported better improvements when they were followed up than the patients who received their results, suggesting that simply getting the results of an MRI scan may be sufficiently alarming that people feel less healthy.

Norman Swan: That's later, after hearing about an Australian developed treatment for long standing back pain which seems to be working.

Here's Martin from Western Australia with what's quite a typical story of someone with back pain that won't go away and will be a very familiar journey to you if you're in that boat.

Martin: A few years ago I had my first back pain, it was as a result of sleeping on the floor at a school camp. Then it got progressively worse over a period of two years. I was seeking help from my GP and went through a variety of different specialists trying to find an answer for it.

Norman Swan: And how badly was it affecting you?

Martin: Well, it was affecting all of my movement. I was very guarded in any movement that I made. I refrained from lifting and it got to the stage where any sort of bending was difficult and was something that I completely avoided.

Norman Swan: Were you in pain all the time?

Martin: Pretty much. It would get progressively worse as the day went on, so I would wake up with some level of comfort but by midday it was quite painful, and at night it was severe pain.

Norman Swan: So it was knocking you around a fair bit.

Martin: Yes.

Norman Swan: And what treatment were you having?

Martin: Initially I started to visit my physiotherapist but that would give me relief for a very short period of time and no ongoing benefits. Then I was referred to a surgeon who got me to get an MRI and he pointed out the areas of my back that weren't looking quite right, there was some arthritis beginning and there were some issues with the facet joints, but he didn't think that any kind of surgical intervention was actually going to give me much relief. So then he referred me to a pain specialist to get a cortisone injection, and I had two of those and they were reasonably successful but, again, only for a short period of time.

Norman Swan: Peter O'Sullivan is Professor of Physiotherapy at Curtin University in Perth and has been pioneering a new approach to people with chronic low back pain.

Peter O'Sullivan: For a number of years we've been listening to the stories of people with persistent back pain who are disabled and trying to work out the best approach to take to deal with it.

Norman Swan: Give me the typical story of a person you're trying to help.

Peter O'Sullivan: A typical story might be a person I saw recently who had developed back pain during pregnancy that became very disabling, and then after pregnancy when pain normally resolves it persisted. This person had sought many, many different opinions for her problem and found over a period of years that the problem actually became worse and she became more disabled, was unable to play with the children, was unable to participate in physical activity, became quite despondent, it affected her mood, her sleep. She started avoiding socialisation with the people around her and got to a point where it was almost like a crisis point for her. That presentation is quite typical, and this kind of vicious cycle of development of pain and disability and with that adopting what become protective patterns of movement and behaviour that in themselves are provocative in the long-term…

Norman Swan: So in other words, the way you are trying to look after yourself perpetuates the problem.

Peter O'Sullivan: Exactly, yes, and what we often see is in an acute phase of a problem…like someone sprains their back or has an injury or they might even get out of bed one day, they've been stressed out at work, tense, and they go to roll out of bed and they get back pain…pain is scary and often the body's automatic response is to protect. And from there that can cascade.

So in this person situation she had been told that her pelvis was unstable and she had to protect it, and so people then start adopting these protective habits which may serve a purpose in the short term but in the long term appear to be very provocative.

Norman Swan: So these are people with just back pain.

Peter O'Sullivan: That's right, you know, anywhere between the mid back and the buttocks, but they may have some peripheral spread of pain but predominantly it's back pain.

Norman Swan: Martin, who you heard from before, was one of Peter O'Sullivan's patients.

Martin: Actually I should tell you about my first visit with him because that was the light globe moment for me. The first thing he asked me to do was just move around as I normally would, he asked me to pick something up off the ground and he made a video recording of me moving, and then he sat me down and showed me how I looked when I moved and I realised just how guarded I was in all of my movements. And then he went on to say that a lot of the problem for me was how I had learned to move as a result of the pain.

Norman Swan: Where did you get this notion…you're calling it cognitive functional therapy that's classification based. I mean, my eyes are glazing, but I'm interviewing you because I'm hoping there's something in it.

Peter O'Sullivan: I know, yes, look, there are two components of that. The first is to get a broader understanding of pain, and often a medical approach is very focused on structure. And the idea of looking at back pain is much more than a structural problem, and we know that pain persists…

Norman Swan: So to explain what you're saying essentially is if you were to do an x-ray of somebody's back or even an MRI scan you're not going to find anything…

Peter O'Sullivan: Well, you may find stuff but it may not be predictive of why they have ongoing pain and disability.

Norman Swan: So you can have somebody with a back that looks as if it's been in World War Three and you can have someone whose back looks okay, and they've got very different levels of pain that doesn't really relate to what you see in the MRI scan or the CT.

Peter O'Sullivan: Exactly, or you even have a situation where we know that abnormal findings on MRI are very common and don't strongly predict pain. And often when those findings which are just so common on MRI get told to people, they then start thinking they've got a really big problem they've got to protect. And I think that's one of the big issues we face with imaging is it's so sensitive and not very predictive, and that tends to reinforce this notion that backs should be protected and guarded and you should be careful with what you do, which then tips people into this process of abnormally moving which we see as a mechanism around perpetuation of pain.

We know, for example, someone who's got a fear of movement or negative beliefs about the back are more disabled than someone who doesn't. So their beliefs about pain, whether pain should be protected and guarded and you should avoid doing things or take care to do things, you're more likely to get disabled if that's the approach you take. And there is growing evidence to suggest that the way you move is reflected in how you perceive yourself. So if you think your back is damaged and your back should be protected and you've got a worn disc, then you're much more likely to brace yourself before you move, hold yourself rigid, not move as easily, so you overwork muscles and that splits your back which can potentially load those structures more rather than actually unload pain sensitive structures. And the more they protect themselves, the worse it gets.

Martin: It was more what he said to me that made a difference. He didn't really spend a lot of time doing what physiotherapists would generally do, which is manipulate you and move you around. He helped me to understand that the pain was ongoing because I had come up with new ways to try and avoid hurting my back. He looked at my MRI scan, he told me that the condition of my back was not perfect but he had seen people with far worse backs who could lift reasonably pain-free and that was really encouraging to hear that.

Norman Swan: It would take a fair bit of courage to stop guarding yourself like that. Tell me how you moved towards changing the way you walked and guarded yourself so that essentially your back was freed up.

Martin: There were a few things. One of the first questions he asked me was whether I could touch my toes, and I attempted to get as close to touching my toes as I could, I probably got my hands to about my knees and then I had to give up because of the pain. And over the course of that first session he asked me to try a few movements and reassured me that they were going to be safe, and at one point in the session he asked me just to sit on a chair and lean forward, and then he asked me to see whether I could touch the floor from a sitting position, and then he just told me to stand up. Then he told me to look in the mirror, and I looked at myself touching my toes five minutes after I couldn't do it. And I just broke down and cried, I couldn't believe it.

Norman Swan: Peter O'Sullivan has conducted a randomised trial of this cognitive functional cognitive therapy with good results.

Peter O'Sullivan: We call it a patient centred approach. So each person's story we look at, we look at how the history evolved, the kinds of advice they've been given, their beliefs, their fear, the things they avoid. We then look at their habits of movement and posture, the strategies of movement they adopt, and then we look at unravelling that. We look at retraining normal movement, teaching people to relax before they move, and to actually build a belief that the spine is a very resilient structure, not something that you should protect and guard before you move because you're much more likely to hurt yourself.

Norman Swan: That takes a bit of convincing, doesn't it?

Peter O'Sullivan: It does, and for someone whose experience has been every time they bend they hurt, it's very hard to teach them to actually relax before they bend. So we will teach them in less provocative positions to actually relax and gain movement and then gradually take them back to the very thing that they thought was going to hurt them. We use the example of walking around with a clenched fist. You know, you don't want to hold your back like that all the time. So we give them strategies of breathing to relax into the belly, relaxing their back in a non-weight-bearing position.

Norman Swan: So this is like lying flat you would do that.

Peter O'Sullivan: Yes, and then taking them back up into sitting, and then from sitting we really work hard to stop them guarding and often breath-holding is part of that. And then gradually go from sitting to bend. Normally muscles can switch on and off, and often with pain they switch on and don't have an off switch, so we work with those people just building their confidence to actually take them back into the things that they are frightened of. As they develop their confidence they actually start to feel that actually it feels better, and there's a kind of tipping point. That takes confidence on the part of the therapist and a lot of trust on the part of the patient.

Norman Swan: So as opposed to normal cognitive therapy in a psychologist's room, you're actually readjusting the thinking while somebody is actually exercising or relaxing rather than in the abstract.

Peter O'Sullivan: Yes, absolutely, because unless these people can feel that actually to do the movement is not going to do them harm and in actual fact may be more helpful, that in itself changes their thinking. We see that as the change of behaviour changing the belief rather than the talking in itself.

Norman Swan: So you did a randomised trial of this.

Peter O'Sullivan: Yes, the trial was carried out in Norway, anyone with back pain, with pain that was provoked with movements and postures.

Norman Swan: Chronic back pain, so it had been a lasting a long time.

Peter O'Sullivan: Yes, anything between three months and up to 10 years I think it was, and they also had to be people who had significant impairments. We looked at two treatment arms, one which would be a traditional approach, more using manual therapy, manipulative therapy, and combining that with exercise, and these were with highly skilled manual therapists in Norway. The other arm which we call a cognitive functional approach which is to really look at the beliefs and behaviours of the person and look at challenging them in a graduated manner was the other arm of the study.

Norman Swan: And the results?

Peter O'Sullivan: There was a three-month intervention period and then there's a 12-month follow-up and a three-year follow-up, it’s actually being undertaken at the moment. We found that both groups improved, where this cognitive functional approach showed actually surprisingly large shifts in terms of everything we measured. So we saw both clinically and statistically significant reductions in disability, pain levels, pain episodes, a big shift in terms of their beliefs around their back, that they were less fearful of movement, less fearful of working with pain. We saw there was a shift in their mood. We also found that their pain episodes were reduced and actually they took less time off work because of their pain and didn't seek as much care. So it seemed to have an impact across a whole range of the things that we'd measured, which I think supports that we are changing something about the way the person thinks and moves around their problem, not just treating the symptom of their pain.

Norman Swan: How long did it take before it was having a more permanent effect on you?

Martin: For me the effects were fairly quick. On my second appointment to see him, which was a week later, I had noticeably less pain. When I started to bend forward and use those muscles that hadn't been used for a long time, the effect was fairly instant. Even in a week it was probably half the pain that I'd had before and within a month it was really reduced. I wasn't feeling pain during the day, maybe a little bit at night if it was a tough day.

Norman Swan: And how are you now?

Martin: Well, it's been probably about six months since my last appointment with Peter and there has only been two or three times when it has been quite sore, and the difference for me now is I didn't panic. Pain used to make me panic a lot, but now the mindset is very different. I have pain and I think, all right, I need to do some stretches, and two or three days of getting back into my stretches things seem to be back to normal.

Norman Swan: Martin, and before him Peter O'Sullivan who's Professor of Physiotherapy at Curtin University.

The challenge at the moment for people with chronic lower back pain is to find a physiotherapist who's been trained in cognitive functional therapy, and like most evidence informed treatments, it's still struggling against the weight of professionals thinking their opinion and personal experience is more relevant. So it'll be up to consumers to demand it. Feel free to refer your physio or GP to the Health Report.

I'm Norman Swan and you're listening to ABC Radio National. In a moment, news about a new website for people with back pain, amongst other things.